30.08 Malignant Large Bowel Obstruction: Is Less More?

Posted on January 25, 2017

P. J. Chung1, M. C. Smith1, H. Talus3, V. Roudnitsky2, A. Alfonso1, G. Sugiyama1  1State University Of New York Downstate Medical Center,Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Acute Care Surgery/Trauma,Brooklyn, NY, USA 3Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:
Colorectal cancer is the fourth most common malignancy in the United States, with over 134,000 new cases expected in 2016. Though many of these cases are early-stage and identified on screening colonoscopy, a subset of patients are detected because they present with large bowel obstruction (LBO). These patients are likely to require urgent or emergent operative therapy. Using a large national database we sought to investigate the outcomes of patients who present with LBO as there are several options for managing this condition.

Methods:
Data was collected from the Nationwide Inpatient Sample (NIS) 2010 – 2012. We included patients with a diagnosis of LBO (560.89, 560.9), with a confirmed diagnosis of colorectal cancer (153 – 154). To identify patients with average risk we excluded patients with familial syndromes (e.g. Familial Adenomatous Polyposis), concurrent neoplasms, age <60 years, and missing race data. We calculated the Elixhauser-Van Walraven score to assess comorbidity status. We identified patients that underwent non-surgical therapy (non-invasive or invasive diagnostic modalities, with resuscitation and/or percutaneous drainage, with or without subsequent chemotherapy), diversion alone, diversion followed by either open or laparoscopic resection, colonic stenting alone, or stenting followed by either open or laparoscopic resection, and either open or laparoscopic resection alone. Multiple imputation was performed. Using inpatient mortality as the outcome variable we performed multivariable logistic regression using age, gender, race, insurance status, income status, elective procedure status, hospital size, urban vs rural hospital setting, geographic region, type of procedure performed, tumor location, presence of perforation, and Elixhauser-Van Walraven score as risk variables.

Results:
6,308 patients met the inclusion criteria of which 473 (7.50%) died. The median age was 74.0 years and 80.23% underwent an emergent procedure. After adjusting for all risk variables, age (OR 1.67 [1.39 – 2.00], p<0.0001), perforation (OR 2.85 [1.97 – 4.11], p<0.0001), Elixhauser-Van Walraven score (OR 1.97 [1.71 – 2.27], p<0.0001), and non-surgical management compared to open resection alone (OR 2.06 [1.60 – 2.65], p<0.0001) were predictive of mortality. However laparoscopic resection compared to open was associated with decreased risk of mortality (OR 0.33 [0.17 – 0.67], p<0.0001).

Conclusion:
In this large observational study of patients presenting with LBO due to colorectal cancer, we found that age, perforation, increasing comorbidities, and non-surgical management were associated with a significantly increased risk of mortality, while undergoing a laparoscopic compared to open resection was associated with decreased risk of mortality. Further prospective studies are warranted to study longer term outcomes and better inform operative planning, particularly as less invasive options become more widely available.
 

27.10 Taking Control of Your Surgery: The Impact of a Prehabilitation Program on Major Abdominal Surgery

Posted on January 25, 2017

Y. S. Yin1, L. McCandless1, S. Wang1, M. Englesbe1, D. Machado-Aranda1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction: Surgery causes physiologic stress similar to intense exercise. When the body’s aerobic and metabolic demands are not met, organ dysfunction may occur and lead to unfavorable complications, or worse, potential deaths. The severity of this outcome is largely determined by a patient’s cardiopulmonary reserve. Current preoperative workup focuses mainly on screening and identifying risk factors. Little attention has been devoted to improve cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a “surgical marathon” similar to preparing an athlete for a sports competition.

Methods: Retrospective demographic, (first hour) intra-operative and post-operative data were obtained from patients who underwent colectomy from 2014-2015 and divided into three observational groups: (1) Emergency; (2) Elective Non-Prehabilitation and (3) Elective with Prehabilitation. Enrollment into the prehabilitation program was completely voluntary for both physicians and patients, and referrals were made 4-6 weeks prior to scheduled operation. This program consisted in the following components: 1) MOVE, physical activity measured by a pedometer; 2) BREATHE, pulmonary rehabilitation using an incentive spirometer; 3) EAT, a dietary and 4) RELAX, a stress-reducing – coaching program. Progress was followed by nurse coordinators and compliance was measured by the frequency of engagement into the web portal.

Results: Age, gender, ASA-grade, BMI, operative time, IV fluids and blood loss were similar in all three groups. At 1-hour post-anesthesia, positive physiologic responses characterized by higher systolic and diastolic blood pressure(s) and lower heart rate were observed in the prehabilitation cohort. Mortality was similar in all three groups (~3 %). However, the rate of complications was significantly reduced [14.2 vs. 45%; RR: 0.31 (95% CI: 0.13 – 0.71); p = 0.0082] in the prehabilitation group as compared to non-prehabilitation elective patients. This further allowed a significant reduction in the length of stay [5 days vs. emergency (p < 0.05) and 2 days vs. other elective surgery (p=0.11)]. Hospital savings averaged $6800, which amply offset any cost incurred with the program ($600/patient). In addition, the prehabilitation program was viewed favorably by patients, with a compliance rate of 70%.

Conclusions: Prehabilitation showed positive physiologic effects during first hour of surgery in colectomy patients. Patients engaged in a systematic optimization program experienced an improvement in their clinical outcomes with hospitals being benefited by a shorter length of stay and a reduction in costs. 

27.09 Early Operative Management of Perforated Appendicitis is Associated with Improved Surgical Outcomes

Posted on January 25, 2017

M. M. Symer1, J. Abelson1, T. Sun2, A. Sedrakyan2, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction: Acute appendicitis is one of the most common surgical diseases in the U.S., with up to 30% of patients presenting with perforation. Recent data suggests that it is safe to treat some patients with antibiotics alone. Despite this, there is no consensus on the optimal timing of surgical management. We evaluated 1-year outcomes in early versus delayed surgery for perforated appendicitis in a large administrative database.

Methods: We analyzed the New York Statewide Planning and Research Cooperative database, an all-payer, in- and out-patient longitudinal database which captures all admissions and surgical procedures in New York State. ICD-9 codes were used to identify all patients undergoing appendectomy for perforated appendicitis from 2000 to 2013. Primary outcome was any complication within one year of follow up. Secondary outcomes included length of stay, hospital charges, utilization of laparoscopy, and conservative management failure rate. Outcomes were compared in patients undergoing appendectomy before or after 48h from admission.

Results:31,167 patients ≥18 y.o. age were identified for analysis, 28,015(89.9%) of whom underwent early appendectomy. Patients undergoing immediate appendectomy were more likely to be male (54.8% vs. 45.2% p<0.01), white (69.8% vs. 64.2% p<0.01), and have commercial insurance (53.1% vs 45.4%, p<0.01). Of the 3152 patients initially managed nonoperatively, 1610(51.1%) required surgery on their index admission and an additional 715(22.7%) were readmitted urgently and underwent appendectomy at another admission (failure of conservative management). Only 827(26.2%) made it to interval appendectomy within one year of index admission. Patients undergoing late appendectomy were more likely to have at least one complication (47.9% vs. 33.2%, p<0.01) and less likely to have a laparoscopic procedure (40.0% vs 42.1%, p=0.03). After multivariate adjustment, patients undergoing delayed surgery were more likely to have a complication (OR 1.56 95%CI 1.43-1.69), be readmitted (OR 1.55 95%CI 1.42-1.70), have high hospital costs (OR 4.79 95%CI 4.35-5.27), and have a prolonged length of stay (OR 6.12 95%CI 5.61-6.68).

Conclusion:While recent data have suggested that non-operative management or delayed operative management of appendicitis is safe, there is a paucity of real world data on this topic. In this population-level study of early versus late appendectomy in adults with perforated appendicitis we demonstrate more complications, longer length of stay, and higher costs in patients who do not undergo immediate surgery.

 

27.08 Nationwide Analysis of Active Adrenal Tumors Highlights Perioperative Morbidity in Pheochromocytoma

Posted on January 25, 2017

P. P. Parikh1, G. A. Rubio1, J. C. Farra1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Endocrine Surgery,Miami, FL, USA

Introduction:  Adrenal adenomas are benign neoplasms commonly discovered incidentally on radiologic studies, and >70% are hormonally inactive. The remaining subset of adrenal adenomas, however, is commonly associated with excess production of aldosterone, cortisol or catecholamines. Perioperative outcomes following adrenalectomy for excess hormone producing or “hormonally active” adrenal tumors have not been well defined. This study examines in-hospital outcomes after unilateral adrenalectomy in patients with hormonally active adrenal tumors.  

Methods: A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database (2006-2011) to identify patients who underwent unilateral open or laparoscopic adrenalectomy for a hormonally active or inactive adrenal adenoma. Malignant adrenal tumors were excluded. Patient demographic, comorbidities and postoperative complications were evaluated by univariate and risk-adjusted multivariate logistic regression. Univariate analyses included two-tailed Chi-square and t-tests.

Results: Of 27,312 patients who underwent adrenalectomy during the 5-year period, 78% (n=21,279) had hormonally inactive and 22% (n=6,033) had hormonally active adrenal tumors. Among patients with hormonally active adrenal tumors, 65% (n=4000) had primary hyperaldosteronism (Conn’s Syndrome), 33% (n=1996) had hypercortisolism (Cushing’s Syndrome) and 1.4% (n=85) had pheochromocytoma. Patients with pheochromocytoma had a higher rate of chronic lung disease and malignant hypertension compared to the remaining hormonally active adrenal patients (18% vs 10%, 6% vs 2%; P<0.01). Pheochromocytoma patients also required more blood transfusions intraoperatively than patients with other hormonally active tumors (21% vs 3%; P<0.01). Pheochromocytoma patients also had more postoperative cardiac (6% vs 0.5%; P<0.01) and respiratory complications (17% vs 7%; P<0.01) than patients with other hormonally active tumors. Mean length of stay was 5 versus 3 days for pheochromocytoma patients compared to the remaining adrenal patients, respectively (P<0.01). Furthermore, total in-hospital cost was approximately $50,000 for pheochromoctyoma patients compared to $39,000 for their counterparts, respectively (P<0.01). On risk-adjusted multivariate logistic regression, pheochromocytoma had an independently higher risk for intraoperative blood transfusion (4.2, 95% CI 2.4-7.2) and postoperative respiratory (1.9, 95% CI 1.0-3.3) and cardiac (7.6, 95% CI 2.8-20.2) complications.

Conclusion: Among benign hormonally active adrenal tumors, patients with pheochromocytoma have a high rate of preoperative comorbidities, contributing to significant postoperative cardiopulmonary complications that ultimately lead to longer and more expensive hospitalizations. Such patients at high risk should undergo appropriate preoperative medical optimization and counseling in preparation for adrenalectomy. 

 

27.07 Intraoperative PTH Spikes During Parathyroidectomy May Be Associated with Multigland Disease

Posted on January 25, 2017

R. Teo1, J. C. Farrá1, O. P. Roque1, A. R. Marcadis1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Introduction: Intraoperative parathormone (ioPTH) monitoring is widely used to predict operative success for targeted parathyroidectomy (PTX) using a >50% PTH drop criterion in patients with primary hyperparathyroidism (pHPT). However, the significance of ioPTH “spikes” at the pre-excision measurement during targeted PTX, commonly from gland manipulation by the surgeon, remains unclear with the assertion that multigland disease (MGD) may be missed. This study compares targeted PTX with and without ioPTH spikes using the >50% PTH drop criterion, and determines the effect of ioPTH spikes on operative outcome.

Methods: A retrospective review of prospectively collected data of 783 patients who underwent targeted PTX guided by ioPTH monitoring for pHPT confirmed by elevated serum calcium and parathormone (PTH) levels was performed. All patients had >6 months of follow-up with a mean of 42 months. When a >50% drop from the highest pre-incision or pre-excision PTH level was achieved at 10 minutes intraoperatively, the operation was completed. An ioPTH ‘spike value' (SV) was calculated by subtracting the pre-incision ioPTH value (PI) from the pre-excision ioPTH value (PE) (SV = PE – PI). An ioPTH spike was defined as having a positive SV ≥ 9 pg/ml (≥10th percentile of positive SV). Operative success was defined as eucalcemia ≥6 months after PTX. Operative failure was defined as elevated calcium and PTH levels <6 months after PTX. MGD was defined as persistently elevated ioPTH levels despite removal of one hypersecreting gland, or when removing a single parathyroid gland resulted in operative failure.

Results: Overall, 256 of 783 patients (33%) with ioPTH spikes had a significantly higher rate of MGD (n=21/256, 8% vs. n=21/527, 4%, p<0.05) and bilateral neck exploration (BNE) (n=44/256, 17% vs. n=61/527, 12%, p<0.05) compared to patients without ioPTH spikes, respectively. Accordingly, more ioPTH spike patients also did not meet the >50% PTH drop criterion from the highest PI or PE value at 10 minutes (n=42/256, 16% vs. n=44/527 8%, p<0.05) compared to patients without ioPTH spikes. Of the 42 patients with ioPTH spikes without a >50% PTH drop, 21 underwent BNE (14 met criteria for MGD and 7 had unnecessary BNE) and 21 did not undergo BNE (2 met criteria for MGD). Overall, there were no differences between PTX patients with ioPTH spikes and no-spikes in terms of operative success (97% vs. 98%), operative failure (3% vs. 2%) or recurrence rates (0.8% vs. 1.0%), respectively.

Conclusion: Although patients who underwent targeted PTX with ioPTH spikes had a higher rate of MGD requiring BNE, operative success was similar to those patients without ioPTH spikes. While the presence of ioPTH spikes may increase suspicion for MGD, the ability of targeted PTX guided by ioPTH monitoring in predicting operative success is not affected by spikes and reaffirms the utility of the >50% PTH drop criterion.

27.06 Predictors of Quality of Life in Hepatic Resection and its Prognostic Value

Posted on January 25, 2017

V. Patel2, S. S. Tohme3, K. Bess1, A. Krane1, N. Ahmed1, A. Tsung1, J. L. Steel1  1University Of Pittsburgh School Of Medicine,Department Of Surgery, Division Of Hepatobiliary And Pancreatic Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 3University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:  There is little evidence to show that health-related quality of life predicts survival across all hepatic malignancies regardless of origin. In addition, there is scant literature on what clinical data can predict a lowered health-related quality of life (HRQL).  This study aimed to assess if hepatic resection improved the quality of life of our patient population, if quality of life is a prognostic factor for survival, and to identify predictors of quality of life score.

Methods:  The study was a secondary analysis in which patients were enrolled in one of two prospective studies between January 2008 to November 2011. The Functional Assessment of Cancer Therapy-Hepatobiliary, Center for Epidemiologic Studies-Depression, Functional Assessment of Cancer Therapy-Fatigue, and the Brief Pain Inventory were administered.  Pearson correlations, ANOVA, Kaplan-Meier and Cox regression analyses were performed to test the aims of the study.

Results: 

Of the 128 patients, the mean age was 61 years (S.D.=11.6), 71.9% of patients had stage 4 cancer, 42.6% had hepatocellular carcinoma, and 50.7% had metastatic colorectal carcinoma.  Overall HRQL decreased from baseline at the 4-month follow-up but then improved and surpassed baseline at 8 and 12 months.

Using Cox regression, after adjusting for age, diagnosis, Clavien-Dindo Grade, tumor stage, and extrahepatic recurrence, HRQL prior to surgery predicted overall survival (Table 1).

Depressive symptoms (r=-0.666, p<0.001), pain (r=-0.192, p=0.032), and fatigue (r=-0.468, p<0.001) were significantly correlated with HRQL prior to surgery.  Significant predictors of HRQL at 8 months follow up included extrahepatic recurrence (p=0.002), depressive symptoms (r=-0.640, p<0.001), pain (r=-0.529, p<0.001), fatigue (r=-0.668, p<0.001), tumor macrovascular invasion (p=0.011), and tumor microvascular invasion (p=0.003) (Table 2).

Conclusion:Surgical resection of hepatic malignancies improved HRQL over the course of one year. HRQL is prognostic of survival in patients with hepatic malignancies undergoing surgery while adjusting for demographics, disease-specific factors, and treatment-related factors.  Psychological and disease-specific factors predicted HRQL at baseline and 8 month follow up.
 

27.05 A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI

Posted on January 25, 2017

B. A. Van Den Beukel1, S. Van Leuven1, M. Stommel1, C. Strik1, M. A. IJsseldijk1, F. Joosten2, H. Van Goor1, R. P. Ten Broek1  1Radboud University Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2Rijnstate Hospital,Department Of Radiology,Arnhem, GELDERLAND, Netherlands

Introduction:
Chronic abdominal pain develops in 18-40% of patients who have undergone abdominal surgery. Adhesions are associated with chronic post-operative pain; however, diagnosis and treatment is controversial.  In this study we evaluate long-term pain and healthcare utilization in a prospective cohort of patients who underwent adhesion mapping by cine-MRI, with subsequent treatment determined through a shared decision-making approach. 

Methods:
Patients with chronic post-operative abdominal pain with suspicion for causative adhesions underwent evaluation with cine-MRI. When adhesions were present on cine-MRI, individualized risks and benefits of adhesiolysis were discussed in a shared-decision making process. Patients who elected to undergo adhesiolysis received an anti-adhesion barrier. Pain and healthcare utilization were evaluated by questionnaire at follow up.

Results:
106 patients were recruited, with a median of 19 (range 6-47) months’ follow-up. 79 patients had adhesions on cine-MRI, 45 underwent an operation, while 34 patients elected not to pursue surgical intervention. 27 patients had no adhesions on cine-MRI, five choose to proceed with diagnostic laparoscopy. Response rate to follow-up questionnaire was 86?8%. In the operative group (Group 1), 80?0% of 45 responders reported long-term improvements in pain, compared to 42?9% (difference 37·1%; 95% confidence interval (CI): 14·4%-55·9%) in patients with adhesions on cine-MRI who declined surgery (28 responders, group 2), and 26?3% (difference 53·7%; 95%CI: 27·3%-70·8%) in patients with no adhesions on cine-MRI who declined laparoscopy (19 responders, group 3). Consultation of medical specialists was significantly lower in group 1 compared to groups 2 and 3 (35?7% vs. 65?2% vs. 58.8%; P=0?023). 

Conclusion:
We demonstrate long-term pain relief in two-thirds of patients with chronic pain caused by adhesions, using cine-MRI and a shared decision making process. Long-term improvement of pain was achieved in 80% of patients who underwent surgery with concurrent application of an anti-adhesion barrier. 
 

27.04 Impact of Surgery Start Time on Roux-en-Y Gastric Bypass and Sleeve Gastrectomy Length of Stay

Posted on January 25, 2017

A. Suzo1, B. Needleman1, K. Perry1, S. Noria1  1Ohio State University Wexner Medical Center,General & GI Surgery/Surgery/Medicine,Columbus, OH, USA

Indroduction:

Methods for decreasing length of stay (LOS) in surgical patients typically involve analysis of intraoperative and/or postoperative care. This study aims to investigate the impact of surgery start time and floor admission time on hospital length of stay after Roux-en-Y gastric bypass and sleeve gastrectomy.

Methods:
All patients who underwent index laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at The Ohio State University Wexner Medical Center during FY2014 were identified. Preoperative, intraoperative, hospital stay, and postoperative data (demographics, comorbid conditions, hospital progress timestamps, and complications) were obtained from the electronic medical record. Mann-Whitney tests were used to determine associations between incision time, and time to admission to the hospital floor, with hospital length of stay (LOS).

Results:
A total of 291 patients were identified and included in the analyses. Of these, 174 patients underwent SG while 117 underwent RYGB. Patients who had a first start case had a shorter hospital LOS versus those whose case was later in the day, however the numbers did not reach significance (2.0 vs 2.6; p = 0.092) and RYGB (2.8 vs 2.9; p = 0.653). Interestingly, patients admitted to the bariatric surgery unit from the post-anesthesia care unit (PACU) before 1:00 pm had significantly shorter LOS than those admitted after 1:00 pm for SG (1.7 vs 2.6; p = 0.0006), but not for RYGB (2.5 vs 3.0; p = 0.359). This trend persisted for admission from the PACU before 2:00 pm for SG (1.9 vs 2.6; p = 0.0235) versus RYGB (2.7 vs 3.0; p = 0.8723). However, when the analysis was extended to 3:00 pm, there was no significant difference in LOS for SG (2.0 vs 2.6; p = 0.2127) versus RYGB (2.6 vs 3.1; p = 0.3977).

Conclusion:
Early arrival to the hospital floor is associated with a significantly shorter hospital length of stay for patient undergoing SG. This suggests that strategic scheduling of common surgical procedures may be used to improve patient outcomes and decreasing LOS.

 

27.03 A Novel Stepwise-Regression Model to Predict Lymphedema Risk After Lymph Node Dissection for Melanoma

Posted on January 25, 2017

A. Kelsall1, T. Novice1, B. Chang1, K. Ogu1, J. Noda1, R. Hoogmoed1, J. Loh1, H. Cheriyan1, C. Ky1, M. Martin1, B. Sunkara1, M. S. Cohen1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Secondary lymphedema is a significant complication after axillary (ALND) or inguinal lymphadenectomy (ILND) in melanoma patients. While prior studies have noted pre- and postoperative risk factors, no clinically useful statistical tool exists for predicting the likelihood of a patient developing lymphedema following ALND or ILND. In this context, we used data from the largest single institution cohort of melanoma patients who underwent ALND or ILND to develop a lymphedema risk assessment tool and tested its efficacy in predicting the development of lymphedema in another cohort of patients undergoing similar procedures

Methods: We retrospectively reviewed our prospective database of melanoma patients undergoing either ALND or ILND. The model cohort (N=524;302 ALND,222 ILND) contained patients undergoing procedures between June 2005 and June 2015. The test cohort (N=98;53 ALND,45 ILND) contained patients between November 2015 and June 2016. Patients having bilateral lymphadenectomy, iliac dissections, or preoperative chemotherapy were excluded. Demographic and clinical data were collected from the electronic medical record (EMR). We used stepwise logistic regression to model the impact of various preoperative and postoperative risk factors on the likelihood of developing lymphedema in the model cohort. These models were then used to calculate risk scores for patients in the test cohort, and procedure-specific tercile thresholds were used to assign patients to “low”,“moderate”, and “high” risk categories and clinical outcome incidence was used to evaluate the accuracy of the risk prediction tool.  

Results:Key preoperative factors (ever smoking, stage, and peripheral vascular disease) were included in the preoperative risk estimation model. Three additional postoperative factors (# nodes dissected, adjuvant therapy, and 30-day non-lymphedema complications) were added when estimating risk postoperatively. In the test cohort, “low”, “moderate” and “high” risk patient groups experienced significantly different (each p<0.01) incidences of lymphedema when estimating risk both preoperatively and postoperatively (see table 1). Both the postoperative and preoperative models equally were able to predict and stratify the incidence of lymphedema.

Conclusion:Our findings demonstrate that this novel risk assessment tool can accurately use either pre- or postoperative factors to reasonably predict the risk of developing secondary lymphedema in melanoma patients undergoing either an ILND or ALND. Using such a risk-stratification tool may provide the patient and surgical team important information for surgical decision-making and discussion. 

 

27.02 MELD-Na Score as a Predictor of Anastomotic Leak in Elective Colorectal Surgery

Posted on January 25, 2017

K. Coakley1, S. Sarasani1, T. Prasad1, S. Steele2, I. Paquette3, B. Heniford1, B. Davis1  2Case Western Reserve University School Of Medicine,Department Of Surgery,Cleveland, OH, USA 3University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 1Carolinas Medical Center,GI And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:
In patients with cirrhosis awaiting liver transplantation The Model for End-Stage Liver Disease Sodium Model (MELD-Na) is extensively studied.  Because of the simplicity of the scoring system, there has been interest in applying MELD-Na to predict patient outcomes in the non-cirrhotic surgical patient, and has been shown to predict postoperative morbidity and mortality after elective colon cancer surgery.  Our aim was to identify the utility of MELD-Na to predict anastomotic leak in all types of elective colorectal cases.

Methods:

The ACS NSQIP Targeted Colectomy database was queried (2012 – 201) for all elective colorectal procedures in patients without ascites.  Leak rates were compared by MELD-Na score using Chi-square tests and multivariate logistic regression analysis.

Results:
We identified 44,540 elective colorectal cases (mean age, 60.5 years ±14.4, mean BMI 28.8±6.6, 52% female), of which 70% were colectomy and 30% proctectomy.  Laparoscopic approach accounted for 64.72% while 35.3% were open.  The overall complication and mortality rates were 21% and 0.7%, respectively, with a total anastomotic leak rate of 3.4%.    Overall, 98% had a preoperative MELD-Na score between 10-20.  Incremental increases in MELD-Na score (10-14, 15-19 and ≥20) were associated with an increased leak rate, specifically in proctectomies (3.9% vs 5.1% vs10.7% p<0.028).  MELD-Na score ≥20 had an increased leak rate when compared to those with MELD-Na 10-14 (OR 1.627; 95% CI (1.015, 2.607).  A MELD-Na increase from 10-14 into 15-19 increases overall mortality (OR 5.22; 95% CI 3.55, 7.671).    In all elective colorectal procedures, for every one-point increase in MELD-Na score, anastomotic leak (OR 1.04 95% CI (1.006, 1.07), mortality (OR 1.24; 95% CI, (1.20, 1.27) and overall complications (OR 1.10; 95% CI (1.09,1.12) increased.   MELD-Na was an independent predictor of anastomotic leak in proctectomies, when controlling for gender, steroid use, smoking, approach, operative time, preoperative chemotherapy and Crohns Disease (OR 1.06, 95% CI (1.002, 1.122)). 

Conclusion:
MELD-Na is an independent predictor of anastomotic leak in proctectomies.  Anastomotic leak risk increases with increasing MELD-Na in elective colorectal resections, as does 30-day mortality and overall complication rate.  As MELD-Na score increases to above 20, restorative proctectomy has a 10% rate of anastomotic leak. 

27.01 Transgastric pancreatic necrosectomy – expedited return to pre-pancreatitis health

Posted on January 25, 2017

M. M. Dua1, D. J. Worhunsky1, L. Malhotra1, W. G. Park1, J. A. Norton1, G. A. Poultsides1, B. C. Visser1  1Stanford University,Palo Alto, CA, USA

Introduction:  The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; operative debridement contributes to the substantial risk of pancreatic
and bowel fistulae, which are associated with recurrent hospitalizations and long-term support to manage pain or nutritional requirements. Minimally invasive endoscopic and percutaneous strategies typically require multiple procedures and a prolonged hospital course. We developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.

Methods:  Patients with walled-off, retrogastric pancreatic necrosis who underwent transgastric necrosectomy (TN) during 2009-2016 were retrospectively reviewed. Open TN is performed via an anterior gastrotomy to debride the pancreas through a wide cystgastrostomy in the posterior wall. Laparoscopic TN involves endoscopic insufflation of the stomach for placement of transgastric ports for operative debridement. The cystgastrostomy is left open in both types of TN to allow ongoing internal drainage of necrosis. Endpoints included postoperative complications and mortality.

Results: Forty-four patients underwent TN (9 open, 35 laparoscopic). Operative indications included persistent unwellness (n=26), infection (n=14), pseudoaneurysm hemorrhage failing embolization (n=3), and worsening sepsis (n=1). The median peroperative APACHE II score for the total cohort was 6 (0-27); however, disease severity was higher in the open TN group compared to the laparoscopic TN group (APACHE II score 12 vs 5, p = 0.03) resulting in a longer length of stay (LOS 11 vs 7 days, open vs laparoscopic, respectively, p = 0.01). Clinical outcomes for the total cohort are represented in the attached table.  A majority of the cohort (74%) experienced none (n=23) or minor (n=10) complications. Six patients had postoperative bleeding; 5 required embolization and there was one death. No patient required more than one operative debridement; five patients required percutaneous drainage for residual collections. There were no postoperative fistulae or wound complications.

Conclusion: The transgastric approach to pancreatic necrosectomy allows for effective debridement with a single definitive operation and minimizes the morbidity associated with prolonged drainage, fistulae and wound complications. When anatomically suitable, the transgastric approach (whether laparoscopic or open) is an effective strategy that expedites return to pre-pancreatitis health and offers significant benefits in the recovery of these patients.   

26.10 Early Identification of Deep Space Infection in Colorectal Surgery

Posted on January 25, 2017

J. R. Bergquist1,2, C. B. Storlie2, K. L. Mathis1, J. C. Boughey3, D. A. Etzioni4, E. B. Habermann2, R. R. Cima1  1Mayo Clinic,Division Of Colon And Rectal Surgery,Rochester, MN, USA 2Mayo Clinic,Robert D And Patricia E Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA 3Mayo Clinic,Department Of Surgery,Rochester, MN, USA 4Mayo Clinic In Arizona,Colon And Rectal Surgery,Phoenix, AZ, USA

Introduction:  Key drivers of colorectal surgical-site-infection (C-SSI) occurrence are institution-specific, and early identification of patients who will develop C-SSI requiring readmission remains challenging. We developed an analytic tool which would utilize institution-specific data for C-SSI screening and treatment during index hospitalization. 

Methods:  Elective colorectal resections from institutional ACS-NSQIP datasets (2006-2014) at 2 locations were included. A Bayesian-Probit regression model with multiple-imputation (BPMI) via Dirichlet process handled missing data. The baseline for comparison was a multivariate logistic regression model (GLM) with indicator variables for missing data (e.g., adding a “missing” level to factors) and stepwise variable selection. Out-of-sample performance was evaluated with Receiver Operating Characteristic (ROC) and Net Reclassification Improvement (NRI) analysis of 10-fold cross-validated samples. Primary endpoint was C-SSI requiring hospital readmission. 

Results: Among 2376 resections, deep/organ space C-SSI rate was 4.6% (N=108: Figure-patients 3,4). Among patients developing C-SSI, N=65(60.1%) were discharged prior to clinical diagnosis (Figure-patient 3). The tool identified N=15(23.1%) of these patients prior to discharge (3 requiring re-operation), with 10% false alarm rate. Among patients clinically diagnosed with C-SSI prior to discharge (patient 4), the tool identified C-SSI 4.5 (mean) days prior to clinical identification. Tool performance generated ROC=0.77 and NRI=21.7%, demonstrating high predictive accuracy. When applied to independent validation data (N=478 cases, N=20 SSI), the tool identified during hospitalization 40% of patients discharged then readmitted with C-SSI (ROC=0.75; NRI=8.4%). 

Conclusion: Identification of C-SSI prior to clinical presentation can facilitate early intervention, potentially reducing morbidity, re-admission, and re-operation. Our tool correctly identified a substantial proportion of patients who were discharged and readmitted with C-SSI in two independent datasets. This institutionally-generic analytic tool can improve outcomes and reduce costs associated with readmission and late C-SSI identification.  

 

26.09 Use of Dual Lumen VV ECMO for Neonatal and Pediatric Patients in a Tertiary Care Children’s Hospital

Posted on January 25, 2017

J. L. Carpenter1, Y. R. Yu1, D. L. Cass1, O. O. Olutoye1, J. A. Thomas2, C. Burgman2, C. J. Fernandes3, T. C. Lee1  1Texas Children’s Hospital,Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Critical Care Section, Department Of Pediatrics,Houston, TX, USA 3Texas Children’s Hospital,Neonatology Section, Department Of Pediatrics,Houston, TX, USA

Introduction:

Recent advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the neonatal and pediatric patient population yet there is little data on outcomes related to this technology. Reported complications of dual lumen VV ECMO have included need for venoarterial (VA) conversion and cardiac perforation. We present the evolution and experience of neonatal and pediatric VV ECMO at a tertiary care institution.

Methods:

Records for NICU and PICU patients who received ECMO support from 01/2005 to 07/2016 were reviewed. Comparison groups included cannulation mode and indication for ECMO. Analyses of survival to discharge, complications (metabolic, hemorrhagic, neurologic, renal, cardiovascular, pulmonary, infectious, and mechanical), and decannulation rate were performed with χ2 tests. Kaplan Meier analysis was used to compare survival based on indication for therapy.

Results:

A total of 160 patients (105 NICU, 55 PICU), ages 0 days – 19 years, required 13 ± 11 days of ECMO. Indications were sepsis (8%) and cardiorespiratory failure (92%); of which 44% (n=64) had diaphragmatic hernia. VV ECMO was the primary cannulation mode in 83 patients with a survival of 64%. VA ECMO was used in 77 patients with 54% survival. Nine VV patients (11%) required VA conversion. VV cannulas were placed percutaneously in 45% of patients (n=37) with 16 placed via an existing central line. Ten VV patients were extubated to spontaneous respirations while on ECMO; three survived to discharge. Overall, 74% of patients (n=118) were successfully decannulated and 57% survived to discharge. Since 2010, the frequency of VV cannulation increased from 50% to 85% and the mortality rate was unchanged. VA ECMO was associated with a significantly higher rate of acute intra-cranial hemorrhage than VV (28% vs 9%, p=0.003). There were no differences in survival (p=0.52), complications (p=0.40), or re-operation rate (p=0.85) between VV and VA groups. There were no cardiac injuries with the use of double lumen VV cannulas. Survival by ECMO indication is shown in Figure 1. There is a significant difference in overall survival (p=0.002); septic patients had a median survival of 20 days, whereas patients with cardiorespiratory failure had a median survival of 129 days.

Conclusion:

VV ECMO cannulation is associated with a lower rate of intra-cranial hemorrhage and may be the preferred first-line mode of ECMO support for cardiorespiratory failure.  VV can be an effective mode of ECMO support in the both the NICU and PICU populations, though conversion to VA ECMO may occasionally be necessary.

 

26.08 The Effect of Resident Involvement on Perioperative Outcomes in Bariatric Surgeries

Posted on January 25, 2017

J. Kudsi1, K. Hayes1, R. Amdur1, P. Lin1, K. Vaziri1  1George Washington University,Department Of General Surgery,Washington, DISTRICT OF COLUMBIA, USA

Introduction:

The current surgical residency training is based on a model of graduated responsibility, giving greater responsibility based on an individual trainees’ ability. To assess the effect of this model on care of the bariatric surgery patient; we decided to study the impact of resident involvement in bariatric surgery stratified by level of training. The aim of this study is to assess the impact of resident involvement on perioperative outcome in bariatric procedures including sleeve gastrectomy (SG) and gastric bypass (GB). 
 

Methods:

Four-year retrospective review 2006-2010 of ACS-NSQIP database for 19,616 lap/open GB (87.8%), and 2,730 lap/open SG (12.2%). All concurrent procedures were excluded except: EGD, liver biopsy, wedge liver biopsy, and lap biopsy. Other exclusions included cases with both laparoscopic and open procedures, emergency cases, cases missing PGY, and those with PGY level higher than 5.  

Pre-treatment patient characteristics and outcomes were compared across levels of the resident variable Juniors PGY 1/2/3 (J) vs seniors PGY 4-5 (S) vs no residents (N) using chi-square for categorical variables and analysis of variance for continuous variables. 

13 composite outcomes were compared; wound (superficial surgical site infection, deep wound infection, organ space infection, dehiscence), pulmonary (pneumonia, prolonged intubation, reintubation), sepsis/septic shock, deep venous thrombosis/pulmonary embolism (DVT/PE), bleeding, cardiac (MI, cardiac arrest), renal (AKI, dialysis) and urinary tract infection (UTI), operative time>4h, Length of Stay (LOS)>3days, return to OR, and mortality. All confounding variables were controlled.
 

Results:

There were 19,616 GB (87.8%), and 2,730 SG (12.2%). Surgical assist distribution was: Junior 3,554 (15.9%), Senior 5,406 (24.2%), N 13,386 (59.9%). 

Cases that included Senior residents more often involved African American patients than cases treated by no resident or junior residents. Non-resident cases had slightly lower BMI, fewer non-independent patients, and less COPD, than cases that involved residents. Cases with Junior residents had the highest rate of dyspnea.

There was no difference in mortality. Senior residents had significantly worse outcomes compared to junior and non-residents in LOS>3 days (S 12.4%, J 10.9%, N 8.3%, P<.0001), wound complications (S 3.6%, J 2.8%, N 2.7% P.007), pulmonary complications (S 1.2%, J 0.7%, N 0.9 P .033), sepsis/ septic shock (S 1.3%, J 1.1%, N 0.8% P .0022), cardiac events (S 0.33, J 0.14, N 0.12, P 0.005) and OR time>4h (S 4.16, J 4.11, N 1.6, P < 0.0001). Junior residents had worse outcome in renal complications (S 0.46, J 0.51, N 0.23, P 0.006).

Conclusion:

Bariatric procedures with senior resident assistance have worse outcomes when compared to junior or non-resident assistance. These results suggest further evaluation of the graduated responsibility model in bariatric operative education.
 

26.07 Hospital Variation in Bariatric Surgery Episode Costs in the Commercially-Insured

Posted on January 25, 2017

A. Kelsall1, A. Ghaferi2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  Bundled payments are gaining momentum as a cost-containment measure that will have sweeping impacts on the provision of surgical care. Despite evidence that private payers are increasingly interested in bundled payment models, research on surgical episode cost variation for common procedures, such as bariatric surgery, has largely focused on Medicare beneficiaries and excluded the commercially-insured population. In this context, we examined hospital-level variation in bariatric surgery episode cost for commercially-insured patients in Michigan.

Methods: Using data from a state-wide collaboration between a major commercial insurer and hospitals in Michigan, we retrospectively identified patients undergoing bariatric surgery procedures- sleeve gastrectomy (sleeve) or Roux-en-Y gastric bypass (RYGB)- from January 2009 through October 2014. We included in the analysis only those hospitals that performed a minimum of 30 procedures during the study period (N=9035 procedures, 31 hospitals). We calculated price- and risk-adjusted payments from index admission to 30 days post-discharge. We divided hospitals into quintiles based on average episode cost and examined variation in four components of episode cost, namely index hospitalization, professional fees, post-acute care, and readmissions. 

Results: We found the average risk and price-adjusted payment for a bariatric surgery episode was $12,246. The highest-cost quintile averaged $1,519 (12%) more per episode than the lowest quintile.  Index hospitalization accounted for the largest share of episode payments (73% and 80% for RYGB and sleeve, respectively) and explained much of the variation between top and bottom quintiles (58.3% for RYGB, 35% for sleeve) (fig. 1). Professional fees accounted for a significant proportion of episode payments (19.4% and 13.4% for RYGB and sleeve procedures, respectively) and drove a roughly proportional share of variation between highest and lowest cost quintiles. Readmission and post-discharge payments accounted for disproportionate shares of the variation between quintiles. For example, in sleeve procedures, post-discharge payments accounted for 3.9% of total episode payments, but explained 22.6% of variation between highest and lowest cost quintiles.

Conclusion: Our findings demonstrate substantial variation in bariatric surgery episode costs in the commercially-insured population. While index hospitalization accounted for the largest share of episode costs, variation in other cost components (i.e., readmissions and post-discharge payments) explained a share of variation disproportionate to their contribution to overall cost, suggesting they are potential targets for quality and efficiency-improvement efforts under bundled payment models.
 

26.06 Symptomatic Hematomas Following Cervical Exploration: A Comparative Analysis over 40 Years

Posted on January 25, 2017

A. Jyot1, T. Pandian1, M. H. Zeb1, N. D. Naik1, A. Chandra1, F. J. Cardenas1, M. Mohan1, E. H. Buckarma1, D. R. Farley1  1Mayo Clinic,General Surgery,Rochester, MINNESOTA, USA

Introduction: Cervical hematoma is a highly dreaded complication of cervical exploration and poses a unique challenge due to the combination of its rarity and associated high mortality. Rising endocrine case volumes over the last decade underscore the need for better understanding of this life threatening condition. We previously reported on the incidence (0.31%) and outcomes of this complication from 1976-2000 (Study A). Given that many of these operations are now performed through smaller incisions and as outpatients, we aim to analyze the complication rate and possible changes in trends from 2001-2015 (Study B).

Methods: A retrospective case-control study including 10,138 patients undergoing thyroidectomy and parathyroidectomy from 2001- 2015 was conducted. Cases were matched 1-to-1 for gender, age, type and year of operation. Univariate analysis testing was performed to assess for baseline discrepancies between study groups followed by a conditional logistic regression to identify perioperative risk factors.

Results: Thirty-two hematomas requiring re-exploration were identified (Study B incidence =0.30%, Study A incidence=0.31%). There were 24 women and 8 men (mean age= 58.4±17.1 years), undergoing thyroidectomy (22), parathyroidectomy (8) and both procedures (2). No perioperative risk factors for developing a cervical hematoma were identified. Most hematomas (n=18, 56%) presented within 6 hours of wound closure, while 7 (22%) presented between 7and 24 hours and 7 (22%) beyond 24 hours. This was in contrast to study A where the most common time of presentation was beyond 6 hours (43%). Neck swelling was the most common presenting symptom (n=22, 69%), followed by neck pain (n=8, 25%), respiratory distress (n=6, 19%), dysphagia (n=6, 19%) and wound discharge (n=4, 13%). At re-exploration, 19 (60%) hematomas were found to be deep and 13 (40%) superficial to the strap muscles. The bleeding source was identified in 24 (75%) cases (11 arterial, 8 venous, 3 diffuse oozing and 2 with oozing and venous bleeding). In our study and control groups, vocal cord paralysis/voice change (25 vs. 22, p=0.171), followed by hypocalcemia (5 vs. 3, p=0.708), were common complications, however no complication reached statistical significance. Mean hospital stay was longer in the patients requiring cervical re-exploration (3.1 days vs. 1.6 days, p=0.005).

Conclusion: The frequency of cervical hematomas remains unaltered over 4 decades. Failure to define a high risk population in the current study highlights the need for meticulous hemostasis. With increasing outpatient neck surgery, scrutiny prior to dismissal and clear patient education regarding symptomatic cervical hematomas is imperative.

 

 

26.05 Exponential Decay Modeling Can Define Parameters of the Weight Loss Trajectory After Gastric Bypass

Posted on January 25, 2017

E. S. Wise1,2, J. Felton1, M. D. Kligman1  1University Of Maryland Medical Center,Department Of Surgery,Baltimore, MD, USA 2Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA

Introduction:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-described operation that produces durable and clinically significant weight loss. While factors influencing future weight loss have been studied, temporal patterns of weight loss are less well described. We test the hypotheses that postoperative weight loss may conform to exponential decay, and subsequently, that three-month weight loss can help characterize a patient’s weight loss trajectory.

Methods:

A retrospective analysis of 1,097 consecutive LRYGB patients at a single institution over a ten year period provided the data necessary to generate postoperative weight loss curves. Using pre- and postoperative BMI data, the mean and standard deviation of postoperative BMI as a function of time was obtained, with multiple linear and nonlinear fits tested for optimal conformity. The highest and poorest performing patients at three month follow-up were stratified based on their cumulative rate of weight loss into two strata: <0.3% EBMIL/day (n = 102) and >0.5% EBMIL/d (n = 191). Exponential decay rate constants (λ) were generated for each group, allowing for optimized estimation of time until half of the weight loss is complete (t1/2) as well as plateau BMI (BMIf). Linear regression analysis was used to interrogate the association of λ, calculated at three months and normalized using a BMIf of 25 kg/m2 (λn, 3 mo.), to %EBMIL at 2-3 years, a surrogate for actual BMIf.

Results:

For the entire cohort, one-phase exponential decay provided the best fit for the weight loss function over time (n = 1,097, r = .43, λ (x 103) = 7.3, t1/2 = 95 days, BMIf = 31.4). Patients who performed poorly at three months (<0.3% EBMIL/d, n = 102, r = .49, lambda(x 103) = 6.4, t1/2 = 108 days, BMIf = 38.9) had a smaller λ and a higher BMIf than those who performed optimally (>0.5% EBMIL/d, n = 191, r = .62, λ (x 103) = 9.4, t1/2 = 74 days, BMIf = 26.6; Figure 1A). Normalized rate constants calculated from three-month weight loss (λn,3 mo.) demonstrated a significant correlation with %EBMIL2-3 years (n = 428, P < .001, r = .28, B = -4.1 %EBMIL per unit increase in normalized lambda; Figure 1B).

Conclusion:

We demonstrate that weight loss after LRYGB conforms to exponential decay. This finding necessarily submits that weight loss trajectory is governed by a patient-specific rate constant and a plateau BMI. Further studies are necessary to characterize the patient and institution-specific factors that contribute to these parameters. However, we find that patient performance at three months, as suggested by λn,3 mo, is a significant predictor of long term weight loss in accordance with our hypothesis.

 

26.04 Defining optimal opioid pain medication prescription length following common surgical procedures

Posted on January 25, 2017

R. E. Scully1, W. Jiang1, A. Schoenfeld1, M. A. Chaudhary1, S. Lipsitz1, P. Learn2, T. Koehlmoos2, A. Haider1, L. L. Nguyen1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed Services University Of The Health Sciences,Bethesda, MD, USA

Introduction: Over-prescription of pain medications has been implicated as a driver of the burgeoning opiate epidemic. Accordingly, legislation limiting length of initial opioid prescription, typically to less than 7 days, has been recently passed in several states. The goal of the current project was to describe opioid pain medication prescription patterns following common surgical procedures and to determine the appropriateness of the prescription as indicated by the rate of prescription refills.

Methods: The Department of Defense Military Health System Data Repository (MDR) tracks care delivered to active, disabled, and retired members of the US armed forces and their dependents insured through TRICARE. The MDR was queried for individuals (age 18-64) who had undergone common surgical procedures between 2006 and 2014. Procedures chosen were cholecystectomy, appendectomy, hernia repair, anterior cruciate ligament reconstruction, rotator cuff tear repair, discectomy, mastectomy, and hysterectomy. Individuals with a prior diagnosis of chronic pain, substance dependence, or an opioid prescription within the 6 months preceding the index procedure were excluded. Refill was defined as repeat opioid prescription within 14 days of the end of the initial prescription. Adjusted risk of opioid prescription refill by number of days of initial prescription was modeled using a generalized additive model with spline smoothing.

Results: Among the 203,834 individuals included, the median length of initial opioid prescription was 4 days [Interquartile Range (IQR): 3-5 days] for general surgery procedures, 4 days [IQR 3-5 days] for women’s health procedures, and 6 days [IQR 5-9 days] for musculoskeletal procedures. When adjusted for clinical and demographic factors, the proportion of individuals requiring refill was low, regardless of length of initial prescription and type of procedure (Figure 1). The early nadir in probability of refill was at an initial prescription of 11 days for general surgery procedures (probability of refill = 7.87%), 14 days for women’s health procedures (probability of refill = 11.55%), and 19 days for musculoskeletal procedures (probability of refill = 1.36%).

Conclusions: An opiate prescription after surgery aims to balance adequate pain treatment while minimizing the duration of treatment.  The statistically-modeled optimal initial prescription length appears to be somewhat longer than 7 days for the surgical procedures included here. In practice, the optimal length of opiate prescription lies between the observed median prescription length and the early nadir, or 4 to 11 days for general surgery procedures, 4 to 14 days for women’s health procedures, and 6 to 19 days for musculoskeletal procedures.

26.03 Health Care Consumption and Sick Leave for Persistent Abdominal Pain after Cholecystectomy

Posted on January 25, 2017

S. Z. Wennmacker1, M. G. Dijkgraaf4, G. P. Westert3, J. P. Drenth2, C. J. Van Laarhoven1, P. R. De Reuver1  1Radboud University Medical Center,Surgery,Nijmegen, , Netherlands 2Radboud Univeristy Medical Center,Gastroenterology And Hepatology,Nijmegen, , Netherlands 3Radboud University Medical Center,Scientific Institute For Quality Of Healthcare (IQ Healthcare),Nijmegen, , Netherlands 4Academic Medical Center,Clinical Research Unit,Amsterdam, , Netherlands

Introduction: Annually, 800.000 cholecystectomies are performed in the United States and 22.000 in the Netherlands. Estimated costs of a cholecystectomy in the Netherlands are around 4000 euro’s. Gallbladder removal for symptomatic gallstones appears to be ineffective in terms of pain relief, in up to 40% of patients. Although several studies have reported on persistent abdominal pain after cholecystectomy, there is no literature on the actual burden of persistent pain to the health care system. The aim of this study is to determine health care consumption and the related costs in patients with persistent abdominal pain after cholecystectomy.

Methods: All 146 patients of a previous prospective multicenter cohort study who reported persistent abdominal pain 24 weeks after cholecystectomy between June 2012 and June 2014 were included in this study. Health care consumption was assessed in February 2016 using Patients experience of surgery questionnaire (PESQ), Medical Consumption Questionnaire (iMCQ) and patients’ medical records. Sick leave and productivity loss of (un)paid work were assessed by the Productivity Cost Questionnaire (iPCQ). Costs were calculated according the Dutch “Guideline for performing economic evaluations in health care” and reported in euro's.

Results: The response rate was 85% (124/146 patients), after a mean follow-up of 31.0 months after surgery (SD 6.5). A total of 55.6% (n=69) of patients had additional care for persistent abdominal pain after cholecystectomy; 30.6% received primary care, 37.1% received secondary care, 16% were admitted in the emergency department, and 8.9% of the patients were admitted to hospital. Diagnostic procedures were performed in 33.9% (n=42) of the patients, which revealed gallstone or surgery related causes in nine patients. In 20 patients another diagnosis was found. Additional treatment included use of medication in 17.7% (n= 22) of the patients (10% uses analgetics, 9.6% uses proton pomp inhibitors ). Additional interventions were performed in 7 patients (5.6%). Estimated mean medical costs for persistent abdominal pain since cholecystectomy were €1,239 (SD €3,573) per patient. Subsequent mean costs of sick leave and productivity loss of (un)paid work were €727 (SD €2,163) per patient.

Conclusion: Due to persistent abdominal pain after cholecystectomy, 55% of the patients needed additional health care, and one third of the patients underwent additional diagnostic procedures. Postoperative medical costs and costs of sick leave and productivity loss in patients with persistent abdominal pain are up to 50% of the initial costs of the cholecystectomy.

 

26.02 Timed Stair-Climbing is a Surrogate for Sarcopenia Measurements for Predicting Surgical Outcomes

Posted on January 25, 2017

S. Baker1, M. Waldrop1, J. Swords1, T. Wang1, M. J. Heslin1, C. M. Contreras1, S. Reddy1  1University Of Alabama at Birmingham,Surgical Oncology,Birmingham, Alabama, USA

Introduction: Estimating sarcopenia by measuring psoas muscle density (PMD) has been advocated as a method to accurately predict post-operative morbidity. This method is cumbersome and not feasible for a busy surgeon to use in practice. We have previously demonstrated that a simple timed stair climb (TSC) outperforms the ACS NSQIP Surgical Risk Calculator in predicting morbidity and hospital length of stay. The aim of the present study is to determine whether the TSC is a marker of axial muscle strength and can be used to replace PMD measurements in predicting morbidity.

Methods: From March 2014 to May 2015, 298 patients attempted TSC prior to undergoing elective abdominal surgery. PMD was measured using pre-operative CT scans obtained within 30 days of surgery at the L3 vertebra. Ninety-day complications were assessed using the Accordion Severity Grading System. Multivariable analysis was performed to identify pre-operative risk factors associated with operative morbidity.

Results: A grade 2 or higher complication occurred in 72 (24.2%) of patients with 8 (2.7%) deaths. There was an inverse relationship between PMD and TSC (Figure, P<0.0001) and a direct relationship between TSC and complications (Figure, P=0.04). On multivariable analysis only the decreasing PMD (P=0.018) and increasing TSC (P=0.026) were predictive of post-operative morbidity.  Area under the receiver operating characteristic curves demonstrated no difference between TSC and PMD in predicting complications (AUC 0.72 vs. 0.70, P=0.49).  Both TSC and PMD were superior to the ACS NSQIP Risk Calculator (AUC 0.55, both P<0.05).

Conclusions: Both TSC and PMD are excellent predictors of post-operative morbidity in this population. TSC appears to be a surrogate for axial muscle strength measured by PMD. TSC is an easy tool to administer in lieu of PMD when considering patient outcomes.

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